Illinois Workers' Compensation Commission Motion To Withdraw As Attorney Of Record Form
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1ILLINOIS WORKERS' COMPENSATION COMMISSION
MOTION TO WITHDRAW AS ATTORNEY OF RECORD
_______________________________________________
Case #
WC
________
____________________
Employee/Petitioner
v.
_______________________________________________
Employer/Respondent
I, ______________________________________________ , attorney for the petitioner ____ respondent ____ ,
request permission to withdraw as the attorney of record on this case for the following reason:
_____________________________________________
Signature of attorney
_____________________________________________
Name of attorney and IC code number (please print)
_____________________________________________
Date
IC28 12/04 100 W. Randolph St. #8-200 Chicago, IL 60601 312/814-611
Toll-free 866/352-3033 Web site:
Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084
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